ACT ABA Intake
Preliminary Learner Intake
Parent/Caregiver's Name
*
First Name
Last Name
Your Name [if you are not the caregiver]
First Name
Last Name
Parent/Caregiver Email
*
example@example.com
Parent/Caregiver Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Text me short videos and tips about getting started (Colorado families)
Yes — text me short videos and tips about getting started with ABA. Up to 2 texts a week from (720) 432-8989. Reply STOP to opt out. Msg & data rates may apply.
Learner's Name
*
Patients First Name
Patients Last Name
Learner's Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Learners Insurance Provider
*
Primary Care Provider
*
Learners Diagnoses [Write N/A if not applicable]
*
Diagnosed by
Date of Diagnoses
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Alternate Address (if services are needed in another setting)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Grade level
*
Please Select
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Where does your child go to school?
*
Additional information about school:
Please note some of your child's likes
*
Please note some of your child's dislikes
*
Days/Times Requesting Service - PLEASE NOTE: WE REQUIRE A 10 HOUR PER WEEK MINIMUM
*
Rows
Morning
[8:00-12:00 pm]
Afternoon
[12:00-3:00]
Evening
[3:00-6:00]
Monday
Tuesday
Wednesday
Thursday
Friday
Behaviors of Concern
*
Rows
Occurs at:
Frequency:
Has this behavior ever resulted in harm to self, others or property
Elopement [running away]
Yes
No
Physical Aggression [hitting/kicking others]
Yes
No
Screaming/Yelling
Yes
No
Self-injury[Hitting themselves]
Yes
No
Self-stimulatory bx
Yes
No
Tantrums
Yes
No
Other Inappropriate bx
Yes
No
Current and Past Services
*
Rows
N/A
Past
Current
Location
Additional Information
Never
Speech Therapy
Occupational Therapy
Physical Therapy
ABA Services
Early Intervention
Other
How did you hear about us?
*
Insurance Portal
Another Therapist
Another Parent
School
By word-of-mouth
Flyer
Event
Internet Search/Website
Other
Any referral/medical documents you'd like to share?
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